Mouhsina M
Vadakkencherry
Summary
Experienced and highly skilled healthcare professional with over 9 years of expertise in quality assurance, patient safety, and regulatory compliance. Proven track record in implementing effective quality management systems, leading performance improvement initiatives, and fostering a culture of safety and excellence. Proficient in applying NABH 5th Edition Standards, NABH Nursing Excellence Standards, NABH Certification Standards for Emergency Department, Certification Standards for Mother & Baby Friendly Hospital Initiative, and NABH Digital Health Accreditation Standards to improve patient care and operational efficiency. Strong analytical and leadership abilities dedicated to enhancing patient outcomes and optimizing operational processes.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Assistant Manager Quality
Aster MIMS Kannur
09.2023 - Current
- Achieved and maintained hospital accreditations by ensuring compliance with high standards and quality care
- Successfully renewed NABH 5th Edition accreditation with minimal non-conformities
- Implemented NABH Digital Health Standards, earning Gold accreditation
- Achieved NABH Certification of Emergency Standards assessment with minimal non-conformities
- Involved in the implementation of CAHO's ACE Program standards for CSSD, earning recognition for ACE certification in the Medium Healthcare Organization category
- Coordinate organization-wide quality improvement activities, integrating efforts across all disciplines to enhance patient outcomes and satisfaction
- Develop and implement organizational policies, guidelines, and manuals aligned with accreditation standards, ensuring adherence across the organization
- Conduct process and internal audits in accordance with JCI& NABH standards, identifying and addressing quality issues effectively
- Root cause analysis of the incidents and implementing CAPA
- Facilitate effective functioning of committees to oversee quality initiatives and ensure compliance with standards
- Execute proactive risk assessments across all areas of the organization, implementing mitigation strategies to enhance patient safety
- Review data collection methodologies and critical incident analysis, ensuring accuracy and compliance in reporting
- Facilitate training on quality standards and methodologies for staff, enhancing the quality of clinical care and reporting accuracy
- Identify bottlenecks in processes and develop standard operating procedures in collaboration with department heads, promoting error-free operations
- Conduct trend analysis of quality indicators, preparing comprehensive reports
- Review and address patient grievances related to clinical quality, conducting root cause analysis and implementing corrective measures
- Self-updation with new regulatory guidelines and international quality standards, ensuring the organization's practices align with the latest benchmarks
Senior Quality Officer
KIMS Al Shifa Healthcare Pvt.Ltd
09.2022 - 08.2023
- Successfully completed the NABH 5th edition surveillance assessment with minimal non-compliances, ensuring high standards of patient care
- Implemented the necessary standards for emergency certification, enhancing the quality of emergency services
- Successfully implemented the NABH Nursing Excellence Programme, achieving certification and elevating nursing practices
- Led the implementation of CAHO's ACE Program standards for CSSD, earning recognition for ACE certification in the Large Healthcare Organization category
- Managed NABH, NABL, and CAHO activities to ensure alignment with accreditation standards and ongoing compliance
- Established and maintained essential processes for the QMS, ensuring robust documentation control and adherence to quality protocols
- Developed comprehensive training programs for new staff on QMS requirements, ensuring clarity in their roles and responsibilities in maintaining quality standards
- Implemented an internal audit program to verify compliance with established standards, significantly enhancing the effectiveness of the QMS
- Oversaw the implementation of SOPs, monitoring adherence and identifying areas for continuous improvement
- Supported the collection of quality indicators across departments, facilitating informed decision-making and quality improvement initiatives
- Effectively handled incident reports and complaints, promoting patient safety and ensuring thorough documentation and analysis of adverse events
- Analyzed the effectiveness of the QMS, identifying opportunities for continuous improvement and ensuring that corrective actions are documented and reviewed
- Conducted comprehensive reviews of committee activities and policies, contributing to the governance and enhancement of quality initiatives
- Conducted daily quality rounds, taking necessary corrective actions to uphold high standards of care
- Coordinated the preparation and finalization of essential forms and documentation for quality management processes
Executive - Quality
Avitis Super Specialty Hospitals Pvt. Ltd.
02.2019 - 11.2021
- Interpret and implement quality assurance standards to establish a robust quality system within the hospital
- Develop and manage all functions and policy matters related to the Quality Management System (QMS), ensuring compliance with NABH standards for hospital accreditation
- Conduct gap analysis and coordinate with relevant teams to address and close non-conformities effectively
- Create comprehensive policies, procedures, and manuals aligned with NABH standards to enhance operational efficiency and compliance
- Organize and assist in conducting mock drills to ensure preparedness and adherence to emergency protocols
- Provide training to medical staff, patients, and housekeeping staff on NABH standards to foster a culture of quality and safety
- Perform root cause analysis of incident reports, ensuring the implementation of corrective and preventive actions to mitigate future occurrences
- Facilitate committee meetings and review minutes to ensure effective communication and follow-up on quality initiatives
- Conduct routine internal audits of clinical and non-clinical areas, preparing detailed audit reports to identify areas for improvement
- Coordinate the closure of non-conformities identified during audits, ensuring timely resolution and compliance
- Implement quality indicators across departments, ensuring regular analysis and compilation of data for continuous improvement
- Conduct quarterly trend analysis of quality indicators to monitor performance and identify opportunities for enhancement
Quality Executive Cum Patient Safety Officer
ASTER MIMS Hospital
08.2012 - 01.2014
- Align workforce management objectives with individual, departmental, and hospital-wide initiatives, fostering teamwork and collaboration
- Actively participated in NABH Surveillance Assessments, reaccreditation processes, and certification standards for the Emergency Department
- Coordinated efforts for the NICU accreditation program with the National Neonatology Forum (NNF), ensuring compliance with national standards
- Manage NABH accreditation activities, including gap analysis and system implementations, to enhance overall compliance
- Organize committee meetings, review meeting minutes, and ensure continuous follow-up on action items and statuses
- Conduct root cause analyses of incident reports, implementing corrective and preventive actions to improve patient safety
- Implement and monitor all quality indicators (QIs), facilitating Quality Improvement meetings to drive performance enhancements
- Establish departmental targets, monitor performance, and initiate corrective actions based on root cause analyses if targets are not met
- Conduct internal audits, maintaining detailed records of audit findings and actions taken for continuous improvement
- Organize mock drills and analyze outcomes to enhance emergency preparedness and response
- Develop and implement various quality-related documents, manuals, SOPs, policies, and procedures to standardize practices
- Analyze clinical pathways and departmental indicators for performance insights
- Coordinate weekly Senior Management Committee meetings to facilitate smooth hospital operations and ensure high-quality patient care
- Prepare various reports, including the State of Hospitals, Monthly Management Meetings, Management Information System, and CMS Reports
- Manage daily office activities, establishing priorities to ensure effective operations and support for quality initiatives
- Lead the review and refinement of the Patient Safety Program within the facility to enhance safety measures
- Ensure compliance with the hospital's approved safety programs to safeguard patient well-being
- Conduct facility inspection rounds and grand rounds, coordinating activities with the Hospital Safety Committee to identify and address safety concerns
- Deliver educational presentations to facilitate understanding and implementation of patient safety standards across the organization
- Collaborate with the safety officer to investigate patient safety incidents and issues within the facility
- Coordinate patient safety protocols and provide staff education on safety-related aspects to promote awareness and adherence
Education
MBA - HOSPITAL MANAGEMENT
Kovai Medical Center & Hospital
09.2010
BACHELOR OF SCIENCE - BIOTECHNOLOGY
Hindustan College of Arts & Science
04.2008
BOARD OF HIGHER SECONDARY EXAMINATION - undefined
Cherupushpam Girls Higher Secondary School
03.2005
Secondary School Leaving Certificate - undefined
Cherupushpam Girls Higher Secondary School
03.2003
Skills
- Quality Management Systems (QMS)
- Statutory Compliance
- Process Optimization
- Coordination of Care
- Patient Safety Initiatives
- Audit and Risk Management
- Incident Report Analysis
- Quality Improvement Projects (QIPs)
- Mock Drills
- Patient Safety Programs
- Training and Development
- Data Analysis and Reporting
- Digital Health Integration
Languages
English
Malayalam
Tamil
Personal Information
- Passport Number: T 6877231
- Date of Birth: 08/10/87
- Gender: Female
- Nationality: Indian
Awards
- Best Employee Award, Recognized as the 'Shining Star of the Month' for outstanding performance and contributions to the organization.
- Certificate of Appreciation, Awarded for significant contributions to the MRCP PACES prep course conducted at ASTER MIMS, Kottakkal.
Certification
- Certified Professional for Quality Implementation in Hospitals (CPQIH Basic)
- Participated in Migrating to the 6th Edition NABH Hospital Accreditation Standards Virtual Course 22/12/2024 - 23/12/2024
- Participated in National Workshop & Conference on Healthcare Quality & Patient Safety | 14th & 15th Dec @ Knowledge Hub, Aster Medcity, Kochi
Timeline
Assistant Manager Quality
Aster MIMS Kannur
09.2023 - Current
Senior Quality Officer
KIMS Al Shifa Healthcare Pvt.Ltd
09.2022 - 08.2023
Executive - Quality
Avitis Super Specialty Hospitals Pvt. Ltd.
02.2019 - 11.2021
Quality Executive Cum Patient Safety Officer
ASTER MIMS Hospital
08.2012 - 01.2014
BACHELOR OF SCIENCE - BIOTECHNOLOGY
Hindustan College of Arts & Science
BOARD OF HIGHER SECONDARY EXAMINATION - undefined
Cherupushpam Girls Higher Secondary School
Secondary School Leaving Certificate - undefined
Cherupushpam Girls Higher Secondary School
MBA - HOSPITAL MANAGEMENT
Kovai Medical Center & Hospital
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